A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
Document the infiltration.
Stop the infusion.
Elevate the arm.
Apply a warm compress.
The Correct Answer is B
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Decreased hemoglobin.
Choice A rationale:
Cigarette smoking typically causes an increase in blood pressure due to the nicotine’s stimulating effects on the cardiovascular system, not a decrease.
Choice B rationale:
Smoking is more likely to cause tachycardia (increased heart rate) rather than bradycardia (decreased heart rate) because nicotine stimulates the release of adrenaline.
Choice C rationale:
Somnolence (drowsiness) is not a common adverse effect of cigarette smoking. Smoking usually has a stimulating effect due to nicotine.
Choice D rationale:
Decreased hemoglobin can occur as a result of smoking because it can lead to chronic obstructive pulmonary disease (COPD) and other respiratory issues, which can impair oxygen transport in the blood. Additionally, smoking can cause carbon monoxide to bind with hemoglobin, reducing its oxygen-carrying capacity.
Correct Answer is C
Explanation
The correct answer is C. The nurse should tell the APs to stop the conversation, as they are violating the client's privacy and confidentiality by discussing their personal information in a public area. This is a breach of ethical and legal principles that can harm the client and expose the healthcare facility to liability. The other actions are not appropriate because they do not address the immediate issue or may escalate the situation unnecessarily. Submitting an incident report may be done after telling the APs to stop, informing the client may cause distress or anger, and documenting the event may not prevent further violations.
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